Other·January 21, 2026

Health and Safety Code Section 1424 (d): Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 42, Federal Code of Regulations, Section 483.25, Subdivision (d) (2) Quality of care is a fundamental principle that applies to all treatment and care provided to facility patients. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following: (d) Accidents. The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 Section 72311(a) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, an mor often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Title 22 Section 72523(a) (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/13/25 at 9:28 a.m., an unannounced visit was conducted at the facility to investigate a Facility Reported Incident (FRI) regarding a fall with injury. During the investigation, the Department determined the facility failed to: 1. Provide adequate supervision and assistance to Resident 1 on 09/28/25 while resident was attempting to get out of bed; 2. Activate Resident 1's bed alarm prior to 09/28/25 to notify staff when Resident 1 was attempting to get out of bed; 3. Follow its policy and procedure regarding activation of Resident 1's bed alarm (to prevent falls) after the resident received care, and 4. Implement a care plan to address placement and set up alarm function before leaving the resident unattended. As a result of these failures, when Resident 1 attempted to get out of bed, no alarm sounded to alert staff, and Resident 1 fell to the floor, sustaining an acute displaced right hip fracture (broken bone). A review of Resident 1's "Face sheet," [undated], indicated, Resident 1 was an 88 year-old admitted to the facility on 10/30/24 with diagnoses including: Alzheimer's disease (brain disorder that causes memory loss, confusion, and other cognitive decline), unspecified dementia (loss of brain function), major depressive disorder (low mood, loss of interest or pleasure), recurrent mild muscle weakness, abnormalities of gait and mobility, primary open-angle glaucoma (eye disease leading to gradual vision loss) and history of falling. A review of Resident 1's "Care Plan History" dated 07/1/2025 - 9/29/25, the "Care Plan History" indicated, "Problem Start Date 10/31/2024...At Risk for falls. Goal Safety will be monitored and managed, Resident will remain free from injury. Approach Start Date 12/4/24 activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness. Special Instructions: for safety. Every Shift DAY, EVE, NIGHT...Discipline CNA, Licensed Nurse." A review of "Fall Risk Assessment," dated 7/21/25 indicated Resident 1 had intermittent confusion, poor recall, judgement, and a poor safety awareness. The facility assessed and evaluated Resident 1 to be at risk for falls and indicated "Continue Current Plan of Care." A review of Resident 1's "Physician Order Report," dated 9/13/25 - 10/13/25, indicated, "activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness. Special instructions: for safety. Every Shift; DAY, EVE, NIGHT. Chartable task in POC." A review of Resident 1's "Resident Progress Notes," dated 9/28/25, indicated, "At 1630 (4:30 p.m.), resident yelling for help and RN on duty immediately ran to resident's room and found resident lying on his right side on carpet outside the entrance of his bathroom. Resident was incontinent of bladder, appears resident got out of bed. No call light and/or bed alarm sounded..." A review of Resident 1's "Resident Progress Notes," dated 9/30/25, indicated, "Post Fall documentation; Two falls within a 48-hour period...RN noted that his bed alarm/call light not activated...Contributing factors for occurrence include: poor safety awareness and loss of balance/gait problems, toileting status, Improper use of safety alarms." During an interview on 10/13/25 at 9:28 a.m., the Director of Nursing (DON), verbalized Resident 1 had an extended history of falls totaling 32 falls in five months while at an assisted living facility and has had nine falls since admission to the facility. The DON indicated Resident 1 had a witnessed fall on 9/27/25, and after that fall a bed alarm was placed. The DON stated, "It was at change of shift. The nurse stated they believed the alarm was on, but the Certified Nursing Assistant (CNA) that was involved couldn't recall if the bed alarm was set to on after changing (Resident 1) in bed. When CNAs change a resident, they turn it (bed alarm) off and whoever's attending to a resident at that moment is responsible for turning it on, and that would be either the CNA or the licensed nurse." During an interview on 10/13/25 at 10:50 a.m. a Licensed Nurse (LN 1), stated because (Resident 1) had been falling, the resident has alarms. LN 1 further stated when you put the bed alarm on, it beeps and you can see with the light on the side of the bed that it's on, and the bed alarm needs to be turned on when you leave the resident. During an interview on 10/13/25 at 11:25 a.m., the Assistant Director of Nursing (ADON), indicated Resident 1 was a fall risk and had fallen in the past and that was why the facility had placed alarms on the resident's bed. The ADON indicated she was working when Resident 1 had the fall, but LN 2 was the on-duty nurse who did the assessment. The ADON indicated the resident started to grimace more and did not look like he was able to get comfortable, so a physician was notified, a mobile X-ray was ordered, and the resident was sent out for an evaluation at a General Acute Care Hospital. The ADON further stated, "CNAs should be visually checking the alarms to make sure they are on if the resident is in bed or the tab alarm is on, if they are in a chair, and it's CNAs and nurses who make sure alarms are on." A review of Resident 1's hospital records (History & Physical) dated 9/28/25 indicated an X-ray of Resident 1's right hip reveals a displaced right hip fracture, and the reason for admission was a mechanical ground level fall with displaced acute right hip. During a concurrent interview and record review on 10/13/25 at 11:43 a.m., with the DON, Resident 1's "Point of Care History," dated 9/28/25 was reviewed. The "Point of Care History" indicated, "activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness every shift. The DON indicated Resident 1's bed alarm checks were not done on 9/28/2025 after the change of shift for the evening shift. The DON stated: "the evening shift did not check that the bed alarm was on...It should be checked at the beginning of the shift, and it wasn't." During a concurrent interview and record review on 10/13/25 at 1:05 p.m. with the DON, the facility's Policy and Procedure (P&P) titled, "Use of Resident Alarm devices," dated 12/19/24 was reviewed. The DON agreed and confirmed facility P&P was not followed in this instance. During a telephone interview on 10/16/25 at 3:15 p.m., LN 2 stated "I had heard (Resident 1) calling for help, and I was at the desk at the Nurses' Station and ran to his room. It was when he fell around 4:30 p.m. I did not go into his room before that...There were people in there with him until 3:30 p.m., because they were changing all the linens...I went in there, and he was on the floor, on the carpeted section, on his right side, and I didn't see the bed alarm on and there was no call light pressed. So, there was nothing prior to that for me to be alarmed of, aside from him yelling for help. I looked at the bed to see if the alarm was on, and it wasn't." LN 2 verbalized bed alarms should be on when the resident is in bed. LN 2 further stated on initial assessment, the resident seemed shaken up, and there was no complaint of pain until later when the facility transferred the resident to his bed. In summary, the facility failed to: 1. Provide adequate supervision and assistance to Resident 1 on 09/28/25 while resident was attempting to get out of bed; 2. Activate Resident 1's bed alarm prior to 09/28/25 to notify staff when Resident 1 was attempting to get out of bed; 3. Follow its policy and procedure regarding activation of Resident 1's bed alarm (to prevent falls) after the resident received care, and 4. Implement a care plan to address placement and set up alarm function before leaving the resident unattended. As a result of these failures, no alarm sounded to alert staff when Resident 1 attempted to get out of bed, and Resident 1 fell to the floor, sustaining an acute displaced right hip fracture. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result therefrom.